1700936234 NPI number — KOEBERS PROSTHETIC & ORTHOTIC LAB INC.

Table of content: (NPI 1700936234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700936234 NPI number — KOEBERS PROSTHETIC & ORTHOTIC LAB INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KOEBERS PROSTHETIC & ORTHOTIC LAB INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700936234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
741 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61606-1953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-334-5705
Provider Business Mailing Address Fax Number:
888-663-6322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3834 W IRVING PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-539-7333
Provider Business Practice Location Address Fax Number:
773-539-5535
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOERTZEN
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-676-2276

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01680020 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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